19Using Social Marketing to PromoteHandwashing with Soapfor a Healthier Vietnam

Hoang Minh Doan and Van Dao Truong

Chapter OverviewDiseases such as diarrhea, hepatitis, helminthic infections, and other infec-tious diseases resulting from poor personal hygiene remain prevalentworldwide. This chapter reports on Vietnam’s Wash Your Hands with Soapcampaign that encouraged young children and their mothers to wash theirhands with soap. A number of challenges were identified, including the poorsanitary conditions in local schools, the misperception of the efficacy ofwater-only handwashing, the consideration of communication as the key toolof intervention, and health officials’ red-tape practices. Yet, there wereopportunities such as governmental agencies’ coordination, internationaldonors’ financial support, and Unilever’s substantial resources, and marketingskills. Informed by the exchange theory and social learning theory, free soapwas distributed to local households and public areas in targeted regions by theClean Hands Task Force. The Clean Hands Toolkits were also developed, andthe Clean Hands Squad Game offered. The campaign raised the awareness ofand engaged with not only the target audience but also the wider public in thepromotion of handwashing with soap. Its scope of implementation wasexpanded from 18 provinces to 50, reaching 26 million people. The pro-portion of population who reported washing hands with soap rose from 14.6to 66.5% in targeted areas.

H. M. Doan (&)Department of Marketing, National Economics University, Hanoi, Vietname-mail: dhminhmkt@gmail.com

V. Dao TruongSchool of Tourism and Hotel Management, North-West University,Potchefstroom, South Africae-mail: vabdao83@yahoo.co.uk

© Springer Nature Switzerland AG 2019D. Z. Basil et al. (eds.), Social Marketing in Action,Springer Texts in Business and Economics,https://doi.org/10.1007/978-3-030-13020-6_19

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Introduction and Background to the Campaign

Diseases—such as diarrhea, hepatitis, helminthic infections, and other infectiousdiseases related to personal hygiene, a lack of clean water, and poor sanitation—that affect the digestive and respiratory systems remain prevalent in many parts ofthe world. These diseases are responsible for the death of millions of children in lessdeveloped countries (World Health Organization (WHO) 2017), as many people donot have good sanitation habits in general and hand hygiene in particular.According to WHO (2017), diarrhea and pneumonia are among the five leadingcauses of death of children under five years. Handwashing with soap has long beenconsidered as an important preventive measure against gastrointestinal diseases aswell as hepatitis A and E, and hand, foot and, mouth disease (HFMD). This pre-ventative measure has thus attracted increased attention from international institu-tions, development agencies, and governmental organizations.

In Vietnam, many problems persist with respect to awareness and practice ofhand hygiene behavior, particularly the low awareness of the importance of handcleaning with soap for the prevention of disease. A Ministry of Health study (MOH,2016) found that between 1 and 10% of malnutrition cases in children under fivecould be reduced if parents regularly washed their hands with soap. According to anational hygiene survey conducted by the MOH and UNICEF (2007), just 12% ofthe rural populations wash their hands with soap before eating and 16% after usingthe toilet. Overall, 98% of rural residents are unaware that handwashing with soapand clean water is essential for preventing infectious diseases (UNICEF, 2007).

In October 2008, the first Global Handwashing Day was launched by UNICEF,the World Bank, and some development organizations from both the private andpublic sectors (World Bank, 2008). It has since become an annual campaign withthe goal of raising public awareness of personal hygiene, environmental sanitation,and healthy living, as well as promoting handwashing with soap as an effective,low-cost, and easy way to prevent diseases. Although this seems a simple behaviorthat everyone can adopt, in Vietnam, the practice of handwashing is not engaged inas a comprehensive and self-motivated behavior among the population at large,including in medical and healthcare organizations (Curtis, 2005).

Over the period 2012–2016, the Wash Your Hands with Soap for a HealthierVietnam campaign was implemented by the MOH, Ministry of Education andTraining, and the Unilever Vietnam Foundation. Targeting high-risk groups such asyoung children and their mothers, the campaign aimed to change the handwashingbehavior of these target groups and save 25 million children from contractingdiseases caused by viruses and bacteria by 2020 (Unilever, 2012, 2013). Thecampaign encouraged people to wash their hands with soap at five critical times:after using the toilet, before breakfast, before lunch, before dinner, and whilebathing. The campaign received Vietnamese Dong (VND) 50 billion (about US$2.2 million) in grants from Unilever Vietnam, over the specified period (Unilever,2012; Lifebuoy Vietnam, 2013a).

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SWOT (Strengths, Weaknesses, Opportunities, Threats)Analysis

In a project to evaluate the effectiveness of the above-mentioned Wash Your Handswith Soap for a Healthier Vietnam campaign, the authors conducted a SWOTanalysis identifying a number of opportunities and challenges that might haveundermined/strengthened its effectiveness. The results of the SWOT analysis appearin summary form Fig. 19.1. The challenges included the poor sanitary conditionsand unsafe hygiene practices in local schools; the misperception of the effectivenessof water-only handwashing; and the consideration of communication as the key toolfor promoting handwashing, regardless of significant barriers to behavior change.On the other hand, there were opportunities such as the commitment and coordi-nated efforts from governmental agencies, and the support and financial aid frominternational donors. In addition, the substantial resources and marketing skillsemployed by Unilever Company, which has a long history of running hygienepromotion campaigns worldwide and has established collaboration with interna-tional and national organizations, were significant advantages for the campaign tobe successfully implemented in Vietnam. However, the red-tape practices oftenobserved in Vietnamese society could have been potential obstacles preventing thejoint effort from achieving its goals.

OS

W T

Fig. 19.1 SWOT analysis of the campaign

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Strong Resources and Experiences from Unilever

Lifebuoy soap is one of Unilever’s fastest-growing brands and considered theworld’s number one antibacterial soap brand. Thanks to its large-scale handwashingprojects worldwide (29 countries with 379 million people reached over the period2010–2016), the brand has gained substantial social marketing skills and knowl-edge, which allows it to deliver the opportunity for effective handwashing behaviorchange at a low cost. The brand’s international experience (as mentioned) in run-ning joint public–private programs was also an important asset for this campaign tobe implemented effectively in Vietnam.

Effective Public–Private Partnerships

Through its extensive hand hygiene promotions in different countries, Unilever hasachieved acceptance by—and the cooperation of—international and national healthinstitutions, such as the Royal Society of Public Health and the London School ofHygiene and Tropical Medicine (Unilever, 2016). Governmental health organiza-tions, having experience in public communication and favorable access to remotecommunities, coupled with the marketing expertise of a private partner, signifi-cantly enhanced the campaign’s effectiveness.

Potential Red-Tape Behaviors of Local Health Officials

The Vietnamese administrative system is generally known for its bureaucracy, andits public health sector still exhibits many limitations, difficulties, and challenges(Puffer, 2015). Social marketing projects, especially those that involve public–private partnerships in the health sector, are still rare. Vietnamese health officialswho have insufficient social marketing experience might hinder the campaign fromrealizing its full potential.

Commitment and Coordinated Efforts from GovernmentalAgencies to Improve National Water Supply and Sanitation

In 1998, Vietnam released a rural water supply and sanitation strategy, while theNational Target Program on Rural Water Supply and Sanitation had been in placefor years (UNICEF, 2007). In addition, the Rural Water Supply and SanitationPartnership, made up of relevant ministries and nearly 20 international organiza-tions, has been active since 2006 to strengthen the coordination of efforts toimprove the national water and sanitation situation in Vietnam (UNICEF, 2007).

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Substantial Support and Financial Aid from InternationalDonors

A number of donors, including UNICEF, WHO, and the World Bank, strengthenedtheir support for sanitation, hygiene, and water supply improvements in Vietnam.This included technical and managerial assistance for policy making as well ascapacity building at the local level. Investment in Vietnam’s water and sanitationwas estimated at about US$10 million per year, including government and externalsources. The key financial partners also included the Asian Development Bank, theFrench AFD, Danida, AusAID, JICA, and Finida (UNICEF, 2008).

Poor Sanitary Conditions and Unsafe Hygiene Practicesin Local Schools

The sanitary conditions in rural Vietnamese schools were poor. UNICEF’s (2007)national survey on sanitation and hygiene showed that the quality of sanitaryfacilities in households, schools, and public areas and the lack of safe hygienicbehaviors remained issues of great concern. About 88% of schools in rural regionsdid not possess adequate toilet facilities, and more than a quarter did not havetoilets. As a result, students had to relieve themselves in forests, gardens, fields, oron riverbanks (UNICEF, 2007). Although personal hygiene education was includedin school curricula, the survey showed that just 36% of schools had handwashingareas, while a mere 5% had soap available for handwashing (UNICEF, 2007).Research suggests that the availability of a water supply and the condition ofhousehold sanitary facilities greatly influence handwashing behavior. Thus, difficultliving conditions may limit people’s response to sanitation interventions (Rhein-länder et al., 2010).

Misperception of the Effectiveness of Water-OnlyHandwashing, Making Behavior Change Difficult

Some misconceptions were identified among the target audience as critical obsta-cles to campaign interventions, including their belief and behavior with respect tohand rinsing using just water, low awareness of the importance of using soap forhandwashing, high rates of forgetting to wash hands before and after contact withfeces (Nguyen et al., 2011). For example, while 92% of mothers reported rinsinghands at critical times, 60% of those who rinsed their hands with water did not feelthat soap was important or necessary and many mothers stated that “soap was tooexpensive” (Nguyen et al., 2011).

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Communication Remains the Key Tool for PromotingHandwashing

Although the local government has employed a range of state propaganda instru-ments and mass media to promote hygienic behaviors, the achieved results seemstronger in terms of awareness than in actual behavior change (PSI Vietnam, 2016).This also holds true with foreign-funded campaigns aimed at promoting hand-washing with soap. For example, the Vietnam Handwashing Initiative (HWI),launched by the MOH and funded by the Danish Embassy in Vietnam, combinedmass media with interpersonal communications to disseminate information aboutthe threat of diseases associated with water-only handwashing (Nguyen et al.,2011).

Target Audience

The campaign targeted elementary school children and their parents countrywide. Itfound that the audience’s belief that washing hands with water alone was sufficientwas a major barrier to behavior change (Curtis, 2005). Indochina Research’s (2007)survey indicated that both the children and their parents perceived cleaning handswithsoap as time-consuming; that in some rural areas, the cost of buying soapwas reportedas a reason for not using it when washing hands; that parents also perceived the timerequired to teach their children how towash their hands properly as an additional cost;that children of this age are vulnerable to infectious viruses, but are not aware of therisk of diseases related to unhygienic behaviors; and that they tend to be hasty andhence reluctant to wash their hands, and if they do, it is just with water.

Campaign Objectives

The campaign’s objective was that, over the specified period (2012–2016), thetarget audience understand the importance of personal hygienic behaviors for dis-ease prevention and practice handwashing with soap at five critical times, as noted:after using the toilet, before breakfast, before lunch, before dinner, and whilebathing (Unilever, 2012, 2013, 2014, 2015, 2016).

Positioning

The campaign positioned itself as being among the few in Vietnam that focusedexclusively on young children and their parents. Handwashing with soap waspositioned as a fun and easy behavior that helped prevent diseases and in this way

288 H. M. Doan and V. D. Truong

contributed to building a healthier Vietnam. Since children like to become heroes,the act of handwashing with soap was associated with a brave man fighting againstbad enemies (harmful infectious germs) to save the Earth.

The campaign also approached handwashing behavior change by emphasizingfive core principles of all Lifebuoy-sponsored campaigns in other countries: disgust(germ contamination), nurture (mother and child interaction), affiliation (group ofheroes fighting against bad enemies), habit (mothers and children to repeat properhandwashing until they stick), and pledging (mothers and children taking pledgespublicly).

4Ps and Implementation

The design and implementation of the campaign interventions were based on theexchange theory from commercial marketing and the social learning theory frombehavior psychology. The 4Ps (product, price, place, and promotion) are summa-rized in Table 19.1.

Table 19.1 Summary of 4Ps

Product Price Place Promotion

Soap Free <1600 communitiesin 18 provinces

Members of the CleanHands Task Forcedistributed free soap tolocal households and atpublic areas; 5-minfilms are made asreality shows andbroadcasted on HTV3channel; fun musicvideos demonstratedhandwashing with soapbehavior

Clean Hands Toolkitsconsisting of Lifebuoydisinfectant, ahandwashing comichandbook, a 3D ruler,and a pledge bracelet

VND45,000(about US$2)

A Web site (http://biet-doi-tay-sach.muare.vn/) wascreated so that thetoolkits could bepurchased

Members of the CleanHands Task Forcetravelled to schoolsnationwide to raiseschool children’sawareness ofhandwashing with soapand the toolkits inparticular

Clean Hands SquadGame

Freeregistrationandparticipation

Schools in differentprovinces nationwide

Annual GlobalHandwashing Day

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The Clean Hands Task Force in Action Reality Shows

A key driver of the campaign, the Clean Hands Task Force (Fig. 19.2) whosemembers included candidates of The Voice Kids Vietnam 2013 was formed. FromDecember 2013 to May 2014, the said Task Force travelled to more than 1600communes in 18 provinces nationwide to promote handwashing with soap and dailycleaning among children, establish the habit of hand hygiene, and urge people tojoin the team to communicate the message to the wider public. Free soap wasdistributed to local households and provided at public places, which helpedencourage people to practice handwashing with soap at home (i.e., free soap inexchange for handwashing behavior). At each of the Task Force’s destinations, afive-minute film was recorded and developed as a reality show. A total of ten filmswere broadcast in Sunday primetime on the HTV3 television channel. Fun musicvideos also demonstrated the five critical times and six proper steps of handwashingwith soap to assist schoolteachers and parents in teaching children (LifebuoyVietnam, 2013b). The Task Force organization not only helped to disseminate thecampaign message to the target audience (children) and made them more respon-sible for protecting their health (by washing hands with soap) but also allowed localparents to learn from practical experience and act as role models for their children.In addition, the sending of the Task Force to local destinations suggests theimportance of establishing rapport and partnership with community members indisseminating the message and encouraging handwashing behavior.

Fig. 19.2 Members of the Clean Hands Task Force. Source Photograph from trailer Clean HandsTask Force, Lifebuoy Vietnam YouTube Channel, 2013

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The Clean Hands Toolkit

The Clean Hands Toolkit (Fig. 19.3) consisted of Lifebuoy disinfectant, a hand-washing comic handbook, a 3D ruler, and a pledge bracelet. Released in October2014, the toolkit was intended to make handwashing more enjoyable for childrenand also to support parents in teaching hand hygiene to their children (Unilever,2014). Every step of handwashing was associated with an interesting adventure.Through each “challenge,” children discovered new things without being aware thatthey were learning. Finally, like “adults,” the children were asked to sign a com-mitment to wash their hands properly. The toolkits were available for purchase athttp://biet-doi-tay-sach.muare.vn/, at VND45,000 each (about US$2). Members ofthe Clean Hands Task Force travelled to local schools nationwide to raise schoolchildren’s awareness of the importance of handwashing with soap as well as of thetoolkits in particular. For each toolkit sold, Lifebuoy donated two soap bars to theYoung People’s Charity Journey in support of medical treatment and housing forchildren in remote areas. The objective was to distribute 200,000 soap bars to ruralchildren and communicate proper handwashing practices to over 100,000 people in50 provinces and cities (Muare, 2014).

The Clean Hands Squad Game

In October 2015, the fun and exciting Clean Hands Squad Game (Fig. 19.4) wasreleased, which attracted substantial attention among young children and theirparents countrywide. The game was promoted in schools throughout the country onthe occasion of the annual Global Handwashing Day, where registration for par-ticipation was free. In this game, children played the role of space heroes of the

Fig. 19.3 Clean Hands Toolkit. Source Muare (2014)

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Clean Hands Squads, who fought against and killed ten harmful bacteria fromenemy planets in the galaxy, helping the lifeboat land safely in Vietnam on ajourney to protect the health of 25 million children by 2020. In each round, childrenlearned about common pathogens that cause infections such as the flu as well as redeyes and boils and got to understand the importance of washing their hands andbody with antibacterial soap. Designed to be simple and fun with useful content,this game served to assist parents in teaching their children how to protect them-selves. For every successful registration in the game, Lifebuoy donated five healthtoolkits to children in rural and remote areas (Giadinhvatreem, 2015).

Campaign Evaluation

The campaign’s progress was tracked annually over the five-year period. Its scopeof implementation was expanded from 1600 communes in 18 provinces at thebeginning, as indicated, to reach six million people by 2014 and 26 million in 2015(Unilever, 2015). The campaign not only engaged its target audience (i.e., childrenand parents) but also members of private and public sectors (e.g., members of theYouth Union and government organizations) as well as the wider public in thepromotion of handwashing with soap behavior, as evidenced by their participationin campaign activities organized. The Unilever Vietnam Foundation providedfunding for the organization of the annual Global Handwashing Day. PSI Viet-nam’s (2016) survey of 1200 rural households in Tien Giang and Dong Thapprovinces indicated that 74.5% reported handwashing with soap and about 84% ofrural residents were aware that handwashing with soap is important after defecating,

Fig. 19.4 Clean Hands Squad Game. Source Photograph from trailer Clean Hands Squad Game,Lifebuoy Vietnam YouTube Channel, 2015

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compared to 68% of those who stated that this practice is important after eating.Overall, the proportion of population who reported washing hands with soap rosefrom 14.6 to 66.5% in targeted areas (Unilever, 2015). Details of specific behavioralchange outcomes are not available, given that Unilever Vietnam has not released itscampaign reports. As part of its Sustainable Development Plan, Unilever Vietnamis committed to helping improve the health and well-being of more than one millionpeople, in which handwashing with soap remains a critical component that will notonly be sustained in previously targeted areas but also expanded to cover manyothers countrywide (Unilever, 2018).

Lessons Learned

A number of lessons were learned from this campaign. Firstly, the campaign hadtargeted regions with high levels of digestive infections and poor hygienic condi-tions, particularly rural and remote ones. Embracing both elementary school chil-dren and their parents helped address the targeted behavior change morecomprehensively. Secondly, a five-year roadmap with a specific focus for eachperiod made the changes and outcomes significant enough to sustain. Thirdly, thecampaign had created a range of tools and activities for children that were enjoyableand easy to understand. Fourthly, well-organized and managed partnerships fromtwo governmental agencies (MOH and Ministry of Education and Training) and acorporate entity (Unilever’s Lifebuoy) secured the necessary resources and facilitiesto implement the campaign effectively. Fifth, although the product element waswell developed, with a variety of tools and activities (reality shows, fun musicvideos, a game, and Clean Hands Toolkits), some products might not be easilyaccessible to those in rural areas, such as computer games. Finally, it was notpossible to compare behavioral change in the target audience before and after thecampaign, given that information about the campaign’s formative research andoutcome measurement was not available (Unilever, 2012, 2013, 2014, 2015, 2016).

Discussion Questions

1. Evaluate the campaign’s targeting and positioning strategy.2. How were the barriers to behavior change in the target audience addres-

sed? How do you evaluate the effectiveness of the price element in thiscampaign?

3. What would you recommend to enhance the campaign’s effectiveness?

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